Hello everyone, I'm Saurabh Joshi, an interventional cardiologist, and we'll be talking about transradial artery access site complications. So transradial artery access site complications can be divided into two categories. One is intra-procedure or post-procedure, and both of these can be further classified into bleeding complications or non-bleeding. During the procedure, the bleeding complication is usually due to radial artery perforation, and the non-bleeding complications are radial artery spasm, which in rare circumstances can be very severe, leading to entrapment of catheter, and if forcefully sheath or catheter is removed, can lead to traumatic eversion. There can be arterial dissection or catheter kink. Post-procedure, similarly, bleeding complication can happen from radial artery perforation, which was masked during the procedure after the sheath or catheter removal. The tamponade effect is taken off and may present with swelling in the forearm or arm because of the perforation, or it could be because of ineffective hemostasis at the access site, leading to hematoma. Non-bleeding complications include radial artery occlusion. They're mostly asymptomatic, rarely presenting with some symptoms. Non-bleeding complication also includes swelling at the access site, which could be because of CO2 aneurysm or AV fistula, rarely nerve damage or regional pain syndrome and infection. So radial artery spasm, this can happen during the procedure at the time of getting an access, which is under puncture-induced radial artery spasm, or during the procedure after the sheath insertion due to manipulation of the catheter or catheter exchange. So the way to manage puncture-induced radial artery spasm is with non-pharmacologic maneuvers like a BALVE maneuver, where one can apply warm compress to the forearm for a few minutes that can lead to vasodilation. Also can do flow-mediated dilatation where one needs to apply blood pressure cuff on the ipsilateral arm, inflate the cuff around 30 to 50 millimeters above the systolic blood pressure and leave it for a few minutes. Once the blood pressure cuff is deflated, it leads to blood flow-mediated vasodilation. If non-pharmacologic measures do not work or are in sync with that, one can use pharmacology, which includes nitroglycerin that can be given locally at the access site or in the forearm or systemically sublingual. To minimize the puncture-induced radial artery spasm, one can use ultrasound to reduce the number of attempts and ultimately reducing radial artery spasm. During the procedure, if one encounters mild radial artery spasm, one can take care of that with administering vasodilators, that is spasmolytic therapy, which could be nitroglycerin. One can choose calcitonib blocker like parapamil, tiltiazem, or nicardipin. Also can increase sedation, can repeat sedation. If the spasm does not respond to that, can repeat multiple rounds of it, keeping an eye on the blood pressure and breathing. Also the same as before can use flow-mediated vasodilation with blood pressure cuff on the ipsilateral arm, warm compresses for which one can use a surgical towel dipped into warm water, forearm heating can give nitroglycerin, can also use solutions like Viperslide or Rotaglide. In rare circumstances, the radial artery spasm can be very severe and may not respond to all these maneuvers. In that situation, one may need to increase the sedation and have the patient get propofol for deep sedation. At this stage, one may have to call anesthesia and administer propofol. Rarely may have to induce general anesthesia to help relieve the spasm. Next is radial artery perforation. Radial artery perforation can be suspected during the procedure if there is ipsilateral forearm arm swelling. To confirm it, one should perform an angiogram. With angiogram, once perforation is confirmed and the site is located where the perforation is, the next question to ask is if we have a wire across the perforation. If you do have a wire across the perforation, then advancing a guide catheter with a technique called balloon-assisted tracking to minimize any further trauma to the artery. If successful, advancing the guide catheter or longsheet can lead to tamponade effect and can minimize the bleed or can completely stop it. In that situation, one can continue with the planned procedure and once the procedure is over, should again repeat an angiogram and look for the perforation or the bleeding. If it's still present, then we'll have to consider giving a reversal agent for anticoagulation that is protamine. Weigh it against the risk of ischemic event of the coronary in case a stent was placed. Hemostasis can be achieved with inflating a blood pressure cuff above the systolic pressure. Also for hemostasis, not responding to other measures, hemostasis can be achieved with balloon tamponade. If you have a wire across, can advance a balloon across the site of perforation, inflate it and then leave it for a few minutes. If it does not respond to balloon tamponade, one can pursue deploying a covered stent to see the site of perforation. At the end, if hemostasis is achieved, can have a compression bandage to maintain some pressure. If these maneuvers do not work and continues to have bleeding, may need surgical consultation and surgical intervention. If perforation is identified but do not have a wire across the site of perforation, one can try to see if they can safely wire across. But if not, then the balloon tamponade or deploying a covered stent is not an option. Other maneuvers can be tried, including the blood pressure cuff or compression bandage to stop bleeding and reversing the anticoagulation with protamine. But usually in this situation, if bleeding continues, then would need surgical intervention. Radial artery occlusion, it is one of the most common radial artery access site complication. Usually goes unnoticed. The incidence depends on when one looks for it. Soon after the procedure, if you look for it, the rates are very high and if you look for it a month out, the incidence reduces because radial artery occlusion many times self-recanalysis. Mostly asymptomatic. Prevention is the key and to prevent it, it's important to decrease the number of attempts. So for that, one should use ultrasound. Avoid radial artery spasm. Use small sheath and catheters. Give anticoagulation that is unfrictionate heparin along with the radial cocktail during the procedure and patent hemostasis. Patent hemostasis is important and what that means is that at the end of the procedure at the radial artery access site, applying a compression band should apply only enough pressure so that there is no bleeding from the access site and the pressure is not too much to prevent any anti-grade flow in the radial artery. So radial artery flow continues to the distal bed and also there is enough pressure to prevent any bleeding. That's how you maintain the patency and reduce the radial artery occlusion to confirm this one can put a pulse oximetry on the ipsilateral thumb or index finger. Look for a waveform and compress the ulnar artery. If the waveform is still present, that means you have a patent hemostasis. Treatment is required only for symptomatic patients, which is rare and this includes anticoagulation or percutaneous revascularization. Hematoma results from bleeding from the access site could be due to ineffective hemostasis or compression band or radial artery perforation, which was not evident at the time of the procedure. Early recognition and its control is of utmost importance because if it progresses, then it can lead to compartment syndrome. So hematoma can be classified using one of the classification is easy classification. There are different gradings from one to five and it is based on the extent of the hematoma swelling from the access site, about five centimeters grade one, then grade two up to 10 centimeter forearm is grade three, beyond that is four. And if patient develops compartment syndrome, it's five. So based on this, most of the management and the frequency of checks is determined. Mostly the hematoma developed at the access site is because of ineffective compression band placement. And this can be taken care of by repositioning the compression band or at times we need to apply an additional compression band. While doing so, while readjusting the compression band, one can apply the blood pressure cuff on the ipsilateral arm inflated over the systolic pressure and leave it at that so that you reduce the integrative flow and there is less bleeding while removing the band and repositioning it at the access site. There should be continuous monitoring of the distal bed perfusion with pulse oximetry. Patient's hand should be elevated, manage pain and blood pressure. Again, early recognition of hematoma progression is important as it can lead to a compartment syndrome. So watch for forearm firmness, neurovascular compromise, hand surgery team should be consulted and should be given a heads up if you're managing a patient whose hematoma is extensive and may need a reversal of anticoagulation with protamine. Once again, you need to balance the risk versus benefit of the ischemic rift if a PCR was performed. Next is radiology pseudoneurysm. This is a rare complication. It presents as a swelling at the access site. Usually it's painless. Occasionally can have some discomfort. The risk factors for development of pseudoneurysm includes use of anticoagulation, inadequate compression post-procedure and multiple attempts at the access site and infection. This is diagnosed with using ultrasound and treatment is mostly conservative with compression. At times may require injection of thrombin to clot the pseudoneurysm and really require closure with a stent or a surgical repair. Next is fistula, another rare complication which again presents with swelling at the access site. This usually has some discomfort and on palpation one will identify or appreciate thrill. Diagnosis again with ultrasound and treatment again includes compression with a hemostatic band. Really requires covered stent or surgical repair. Thank you.

transradial artery access complications

bleeding complications

non-bleeding complications

management strategies

prevention techniques